Managing Managed Care

Our inequitable, inefficient, oftentimes uncaring health care "system," revealed. -- Jeffrey G. Kaplan, M.D., M.S.

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Managed Care Organizations Practicing Medicine (Without a License)

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Aetna refused to pay for a visit of a child with a probable goiter and strong family history who needed diagnostic lab tests—they do not accept rule-outs.  Not long ago, Oxford levied a $50 deductible and $25 co-pay for the most efficacious eardrop we have in our armamentarium; Reason? This drop, containing an antibiotic and a steroid was not available generically; they were forcing me to use a plain ear drop – not what the doctor ordered! Mental Health Parity; Let the HMO's Be Damned!

Care Mgm't, Communication Curriculum Tools and Diagnostic Coding

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Coding systems that support clinical decision-making, 'measurement and management,' communication, especially about transitions of care and outcomes (acuity-adjusted) become the modus operandi of the new Managed Care.

Cutting health care and entitlement costs?!?

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We can sustain recent successes that increase the number of insured, improve the value of health care, reduce waste, and entitlement costs. [Ref.–the Accountable Care–Act (ACA)]. In addition, "healthcare costs can be controlled if we focus on and implement adequately risk-adjusted payment incentives* for a small number of outcomes. A small number of outcomes is critical for consumer understanding and will facilitate healthcare delivery change.

Pay More; Get Less

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The health insurance and managed care industries are strange bedfellows.  Health insurance, however, seems to  work better for health insurance companies than patients, by and large. They, the insurers "like to cite figures showing that 87 cents of every dollar in premiums is spent on medical claims. But a new Senate analysis suggests that for-profit insurance companies are spending much less than that, especially for policies sold to individuals and small businesses.

Quality Assessment--First, Is the Recommended Diagnostic Test or Treatment Efficacious?

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Would you care to see efficacy in new product development where the reduction in mortality for patients so treated takes a back seat to 'The cheaper is first" rule.  In this example, metformin is standard therapy; the more efficacious Lilly product, must wait in the wings. Macrovascular Efficacy:  Microvascular Efficacy: Why doesn't Dr. Jones' opinion about therapeutic efficacy really matter? What if the patient won't or can't take the test or medicine?

Reducing Economic Pain

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The "areas in which the proper reform measures could generate savings that could pay for universal coverage" include, but are not limited to unecessary and presumably unhelpful care, fraud and from the perspective of the physician, extraneous administrative expenses. Unnecessary care is believed to be responsible for as much as 30% of health care spending,2 or up to $830 billion this year alone.

The 4 Main Reasons We Fail Reforming Health Care: Cost Fears, Variation, Poor Collaboration and Understanding

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Approximately 2/5 persons don't understand their insurance coverage, i.e., which healthcare services are being covered under their current plan and, 1 in 5, "have avoided visiting a doctor for a general health concern within the past 12 months because of cost concerns."

Cost is the Big Item in the Value Equation of Health Care and Here's Why

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The main tension about healthcare centers around medical need, quality, access and cost-efficiency, i.e., affordability. To increase "value," one must raise quality, improve access and/or lower the cost of care. 

Not Just an Apple a Day...

“There’s no such thing as alternative medicine [when it comes to "fighting" cancer]. There’s only medicine that works and medicine that doesn’t."   Complementary and Alternative Medicine (CAM) is inviting and has such promise but it is unproved and it can be dangerous. As Paul Offit (Chief Infectious Diseases, Children’s Hospital of Philadelphia) states, “There’s no such thing as alternative medicine. There’s only medicine that works and medicine that doesn’t.”